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Heart Failure





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Definition
Heart failure can be defined as an abnormality
function leading to or of cardiac structure
failure of the heart to deliver oxygen at a rate
commensurate with the requirements of the
metabolizing tissues.

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart
Journal (2012)33


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Heart Failure Statistics
AHA Statistical Update: Circulation. 2009;119:e21-e181
5.7 million people have HF
670,000 new cases in 2006
292,000 annual deaths due to HF
1.1 million hospitalizations per year
Largest Medicare expenditure
$37 billion in 2006
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Heart Failure in Context
One Year Mortality
0
10
20
30
40
50
60
70
80
90
AIDS Leukemia Lung Cancer Pancreatic Cancer End-stage HF with
Optimal Medical
Management
Diagnosis
1

Y
e
a
r

M
o
r
t
a
l
i
t
y

(
%
)

Rose EA, et al. N Engl J Med. 2001 Nov 15;345(20):1435- 43.
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Heart Failure Risk
Common Causes
Ischemic heart Disease
Diabetes
Hypertension
Valvular Heart Disease
ETOH Abuse
Obesity
Cigarette Smoking
Hyperlipidemia
Physical Inactivity
Sleep Apnea

Less Common Causes
Familial Hypertrophic CM
Postpartum CM
Thyroid Abnormality
Connective Tissue
Disorders
Toxin Exposure
Myocarditis
Sarcoidosis
Hemochromatosis
Medication Exposure
Anemia


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Causes of Heart Failure
Coronary Artery Disease: Dead Meat Dont Beat
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Pathophysiology
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Pathophysiology
Hemodynamic changes

Neurohormonal changes

Cellular changes
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Renin-Angiotensin Aldosterone System

http://en.wikipedia.org/wiki/Fil e:Renin-angi otensin-aldosterone_system.png
ACE inhibitors
ARBs
Aldostero
ne
antagonis
ts
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Causes of left ventricular
failure
Volume over load: Regurgitate valve
High output status
Pressure overload: Systemic hypertension
Outflow obstruction
Loss of muscles: Post MI, Chronic ischemia
Connective tissue diseases
Infection, Poisons
(alcohol,cobalt,Doxorubicin)
Restricted Filling: Pericardial diseases, Restrictive
cardiomyopathy, tachyarrhythmia

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Clinical Classifications

Systolic:
Impaired ability of the heart to contract
Weakened muscle, enlarged heart size
Inability of heart to empty
Left ventricular ejection fraction (LVEF) < 4045%
Diastolic:
inability of the heart to relax is impaired
Stiff, thickened myocardial wall but normal size
Inability of heart to fill
LVEF 45%


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Heart Failure with Preserved Ejection Fraction

Heart Failure with Preserved Ejection Fraction (HFpEF)
Systolic Dysfunction
EF < 40%
EF > 40 %
Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200
40
%
60
%
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Clinical Classifications
Backward
Inability of the ventricle to eject its contents,
resulting in elevated filling pressures
Forward
decreased cardiac output and inadequate
tissue perfusion

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Clinical Classifications
Left-Sided
Left Ventricle is weakened or overloaded
Results in pulmonary congestion
Right-Sided
Right Ventricle is impaired
Results in systemic venous overload
May occur independently from conditions affecting
the right ventricle only

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Clinical Classifications
Heart Failure is a Symptomatic Disorder
New York Heart Association-Functional
Classification
Class I: No abnormal symptoms with activity
Class II: Symptoms with normal activity
Class III: Marked limitation due to symptoms with
less than ordinary activity
Class IV: Symptoms at rest and severe limitations in
functional activity
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Clinical Classifications
Acute
sudden onset with associated signs and
symptoms
Chronic
secondary to slow structural changes occurring
in the stressed myocardium
Acute Decompensated
sudden exacerbation or onset of symptoms in
chronic heart failure

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EVALUATION
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Left and Right Heart Failure
Distended Jugular Veins
elevated right atrial pressure
Hepatomegaly
elevated IVC pressure
Peripheral Edema
elevated capillary bed pressure
Pulmonary rales (crackles)
elevated capillary pressure
S3 or S4 gallop
increased LV pressure,
decreased compliance
Orthopnea
increased venous return
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What is the diagnosis?
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What is the diagnosis?
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Pitting edema


( . )
.




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What is the diagnosis?
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JVP Inspection
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Apical pulse

( APEX ) PMI ( point of
maximal impulse )

Pulse deficit
Displaced PMI
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Diagnosis
Modified Framingham Clinical Criteria
MAJOR MINOR
Paroxysmal Nocturnal Dyspnea
(PND)
Bilateral leg edema
Orthopnea Nocturnal cough
Elevated jugular venous pressure
(JVD)
Dyspnea on ordinary exertion
Pulmonary rales Hepatomegaly
Third heart sound (gallop) Pleural effusion
Cardiomegaly on chest x-ray Tachycardia > 120 bpm
Pulmonary edema on chest x-ray Weight loss > 4.5 kg in 5 days
McKee PA et al N Engl J Med 1971; 85:1441
Diagnosis requires 2 major or 1 major and 2 minor criteria
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Its 2:30 a.m.
Youre paged to the ED to see this guy
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What is the diagnosis?
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Evaluation of Heart Failure
EKG
Q waves, LVH, heart block, tachyarrhythmia

CXR
pulmonary edema, other causes of dyspnea

Blood tests
Chemistry panel: renal function, sodium, glucose
Liver function tests
TnI
BNP

Echocardiogram
Function (systolic and diastolic) ?
Structure (LVH, dilation, valves, shunts)

Cardiac catheterization?
Left heart cath and/or right heart cath

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Maisel A. Rev Cardiovasc Med. 2002;3(suppl 4):S13.
Patient presenting with dyspnea
Physical examination,
chest x-ray, ECG,
BNP level
BNP <100 pg/mL BNP 100-400 pg/mL BNP > 400 pg/mL
CHF very unlikely
(2%)
Baseline LV dysfunction,
underlying cor pulmonale or
acute pulmonary embolism?
Yes No
Possible
exacerbation of CHF
(25%)
CHF likely
(75%)
CHF very likely
(95%)
Heart Failure Diagnostic Algorithm
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MANAGEMENT OF
Acute Decompensated HF
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MANAGEMENT OF
Chronic Heart Failure in
Compensatory faze
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Chronic therapy and outcomes in HF
Drugs that decrease mortality:
- blockers
ACE inhibitors
Aldosterone antagonists
Isosorbide and hydralazine


Drugs that increase
mortality:

Dobutamine
Dopamine
Inamrinone
Milrinone
Drugs that may improve
symptoms without worsening
outcome:
Cardiac glycosides
Loop diuretics

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Neurohormonal Antagonists
Why we do what we do
Adapted from: Remme WJ et al. Eur. Heart J. 2001;22:1527-1560.
Events prevented per 1000 patient-hours of treatment
Therapy
Hospitalizatio
ns Prevented
Deaths prevented Evidence
ACE-inhibitor 99 13 SOLVD
Beta-blocker 65 38 MERIT-HF
Spironolactone 138 57 RALES
Digoxin 40 0 DIG
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Diuretic Therapy - Thiazides
The most effective symptomatic relief
With Mild symptoms
Hydrochlorthiaside
Chlorthalidone
Metolazone- Zaroxolyn

Mechanizm of action
Block Na reabsorbtion distal convoluted tubules

Thiazides are ineffective with GFR < 30 --/min

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Diuretics (cont.)
More severe heart failure loop diuretics
Lasix (20 320 mg QD), Furosemide
Bumex (Bumetanide 1-8mg)
Torsemide (20-200mg)

in ascending limb of reabsortion Inhibit chloride : action Mechanism of
loop of Henle results in natriuresis,
kaliuresis and metabolic alkalosis
Adverse reaction:
pre-renal azotemia
, gout , hyperuricemia , dehydration , hypomagnesemia , hypokalemia , hyponatremia
Ototoxicity , dyslipidemia . syncope , postural hypotension , dizziness
Skin rash



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K
+
Sparing Agents
Spironolactone (Aldosterone inhibitor)
recent evidence suggests that it may improve survival in CHF
patients due to the effect on renin-angiotensin-aldosterone
system with subsequent effect on myocardial remodeling and
fibrosis.
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Angiotensin Converting Enzyme
Inhibitors
They block the R-A-A system by inhibiting the
conversion of angiotensin I to angiotensin II
vasodilation and Na retention
Bradykinin degradation its level PG
secretion & nitric oxide
Ace Inhibitors were found to improve survival in CHF
patients
Delay onset & progression of HF in pts with asymptomatic
LV dysfunction
cardiac remodeling

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Angiotensin II receptor blockers

Has comparable effect to ACE I

Can be used in certain conditions when ACE I are
contraindicated (angioneurotic edema, cough)
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Digitalis Glycosides
(Digoxin, Digitoxin)
The role of digitalis has declined somewhat because
of safety concern
Recent studies have shown that digitals does not
affect mortality in CHF patients but causes significant

Reduction in hospitalization
Reduction in symptoms of HF
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Blockers
Has been traditionally contraindicated in pts with
CHF
Now they are the main stay in treatment on CHF &
may be the only medication that shows substantial
improvement in LV function
In addition to improved LV function multiple studies
show improved survival
The only contraindication is severe decompensated
CHF
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Multicenter -ARB mortality trials
Study Drug
Subject
s
Deaths
US Carvedil Carvedilol 1094 65%
CIBIS-II Bisoprolol 2647 34%
MERIT-HF
Metoprolol
CR/XL
3991 34%
COPERINICUS Carvedilol 2289 35%
BEST Bucindolol 2708 NS
Gheorghiade. Circulation 2003;107:1570-5
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Vasodilators
Reduction of afterload by arteriolar vasodilatation
(hydralazin) reduce LVEDP, O
2
consumption,improve
myocardial perfusion, stroke volume and COP
Reduction of preload By venous dilation
( Nitrate) the venous return the load on both
ventricles.
Usually the maximum benefit is achieved by using
agents with both action.
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Positive inotropic agents
These are the drugs that improve myocardial
contractility ( adrenergic agonists, dopaminergic agents,
phosphodiesterase inhibitors),
dopamine, dobutamine, milrinone, amrinone
Several studies showed mortality with oral
inotropic agents
So the only use for them now is in acute sittings as
cardiogenic shock


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Anticoagulation (coumadine)

Atrial fibrillation

H/o embolic episodes

Left ventricular apical thrombus
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Summary of HF Pharmacotherapy
SAVE LIVES IMPROVE SYMPTOMS
ACE inhibitors/ARBs Diuretics
Beta blockers Digoxin
Hydralazine/Nitrates Inotropes
Aldosterone inhibitors TNG, nipride, nesiritide
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Inotropes
are not pressors
Felker GM, OConnor CM. Am Heart J 2001;142:393-401
DRUG SV HR SVR BP
Dobutamine +++ ++ +/- +/-
Milrinone +++ + (SVT) - -
Dopamine* + ++ ++ ++
*assuming moderate dose (2 5 mcg/kg/min)
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New Methods

Implantable ventricular assist devices

Biventricular pacing CRT and CRTD
(only in patient with LBBB & CHF)

Artificial Heart
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Ventricular Assist Devices
Consideration of an left ventricular assist device as permanent or
destination therapy is reasonable in highly selected patients with
refractory end-stage HF and an estimated 1-year mortality over 50% with
medical therapy.
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
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k

2
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0
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Yours patient have to Know?
Salt, Sodium and Natran is the same thing.
Sea Salt is Salt!
Limit Salt to 2000 mg per day.


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Where is Salt Found?
Naturally in most foods.
Bread, Potato, Vegetables
Canned and Prepackaged foods.
Spices high in Salt:
BBQ sauce, bouillon cubes, ketchup.
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How much Salt is too much?
Limit is 2000 mg of salt per day. This equals 1
teaspoon of salt all day.
Stay away from salty snacks- potato chips;
salted crackers; pretzels.
No salt shaker.

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Salt- more information
No canned soups, or processed foods.
Pickled foods have too much salt. Pickles
sauerkraut, olives, all have too much salt.


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Reading Labels

Always read the food label.
How many servings in each package?
Look for the words Salt, Sodium.

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Reading Labels
If Salt or Sodium are in the top five
ingredients DO NOT EAT THE FOOD!
This food would be too much salt for your
diet.
Remember 2000 mg per day.

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Canned Soup
All canned soup has too
much salt for your diet.
One serving of Chicken
Noodle soup has 1800
mg of sodium. All you
can have in one day is
2000 mg.
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How much can I drink?
Do not drink more than 1.5 litres to 2 litres of
fluid per day.
That equals 6-8 cups of fluid all day.
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Kinds of Fluids
1 cup = 250 ml = 8 ounces.

Water, milk, coffee, tea, juices are all
fluids.

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Do Not Drink
Stay away from
Vegetable juices,
Clamato juice, and
tomato juice.
These all have too
much salt.
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Things to Avoid
Limit alcohol use.
Some doctors state no
alcohol.
STOP SMOKING!
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Daily Weights
Weigh yourself daily.
Use the same scale, and weigh yourself first
thing in the morning before breakfast.
Call the clinic if weight increases by two
pounds overnight or five pounds in a few days.
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Rest and Exercise
Make exercise part of your daily routine.
Try to take a mid day REST for 30 - 60 minutes
per day.
When exercising make sure you can walk and
talk. If not, stop walking or slow down.
Stop all exercise if you feel short of breath or
develop chest pressure.
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Lets keep active!
Exercise is like a natural medication: You have
to take it regularly to maintain the benefits!
Take advantage of your good days.
Find a partner for exercise.
Enjoy being active!
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Which activities are good?
Walking, riding a stationary bicycle,
gardening, etc. are excellent activities to
improve your endurance.
20 to 30 minutes 2-3 times per week
Stretching improves your flexibility
Always check with your doctor or nurse if you
plan to increase your exercise.

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What else should I know?
Stop exercise if you feel short of breath or
develop chest pressure.
Do not exercise if:
You gained more than 1 lb from previous
day
If you feel more short of breath then usual

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MEDICATIONS
Remember to always take your medications
at a regular time every day.
Do not skip doses.
Do not self medicate.
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Any
questions